What is a kidney worth?

ByAbraham McLaughlin, Ilene R. Prusher,Andrew DownieJune 9, 2004

Every day, 17 Americans die of organ failure. In Israel, the average wait for a kidney transplant is four years. In response, a global gray market has bloomed. In India, for example, poor sellers are quickly matched with sick buyers from Taiwan. Critics call it "transplant tourism." Proponents say the market is meeting a need.

The Monitor follows three men: an unemployed Brazilian and an ailing Israeli, as well as a South African investigator who helped bust an organ-trafficking ring.

The case raises anew hard legal and ethical questions, such as: Who owns our bodies? Should it be illegal to sell an organ if it could save someone's life? What is the government's role in protecting two vulnerable groups - the poor, who are willingly exploited, and the sick, who are desperate for healing?

On a warm afternoon in Recife, a city on Brazil's northeastern coast, Hernani Gomes da Silva sits alone in the Bar Egipcio, quietly nursing a drink, ruminating about his predicament. He is 32 years old and still lives in his mother's two-room house. Rain comes in through the roof, and cockroaches and rats scuttle across the cement floor. He has three kids, a wife who loathes him, and a mistress 20 years his senior. He is unemployed with no money, no skills, and a criminal record. The future is bleak.

Suddenly the words "we pay people $6,000" leap out at him from behind. His radar clicks on.

"I don't mean to eavesdrop," he says, turning to the bald man sitting at a nearby table. "Were you talking about earning money from transplants?" He has heard of others in Recife who have sold their organs and can't believe his good fortune.

"Yes," says the man.

"Which organ?" Hernani asks.

"The kidney. Why, are you interested?"

"Of course I'm interested."

"What blood type are you?" the man asks.

"O-positive," says Hernani.

The man nods - it's the most compatible blood type. It's 2002 and Hernani has passed the first test for selling a kidney to an organization that will stretch across three continents; make hundreds of thousands of dollars for the people behind it; and rouse the interest of police, politicians, ethicists, and doctors around the world.

Soon Hernani is walking home, dreaming of a motorbike and a roof that doesn't leak.

* * *

More than 5,000 miles away across an ocean, Arie Pach, a stout Israeli lawyer in failing health, sees his future flash before him. It makes him shudder.

As he heads to an appointment on the sixth floor of Jerusalem's Hadassah Ein Kerem Hospital, he walks past the dialysis ward. Below the glare of fluorescent lights, the thin, feeble-looking patients sit in special armchairs hooked up to oven-sized machines that click and whir and simulate the job of the human kidney: They clean the patient's blood. It's a life-preserving process for people whose kidneys have failed, but they have to be connected roughly three hours at a time, three days a week.

In February 2002, Arie's doctors told him his kidneys were beginning to falter. By early 2003, he's had minor surgery to prepare for dialysis, but he is already formulating plans to avoid the ward. "I don't want to be one of those people with big needles in my arm, getting my blood changed in and out of the machine like a car going for an oil change," he thinks.

Then there's the expense of dialysis to the healthcare system - about $45,000 to $50,000 per year. And only some 10 percent of dialysis patients live more than 10 years, according to the US National Center for Health Statistics. Arie has too many things left to do in life. He loves to travel abroad with his wife. One of his two sons will marry this summer. To see any grandchildren, he's got to stick around. But the doctors warn him that his blood could soon start to become toxic. They give him two choices: dialysis or a kidney transplant.

* * *

In the seaside resort city of Durban, South Africa, private investigator Johan Wessels is working in his home office, plinking away at the computer keyboard. The phone rings. It's a woman from the health department. She wants to know if he'd be willing to work on a case under something called the Human Tissue Act.

In 24 years as a police detective and private investigator, Johan has tackled all kinds of cases - smuggling, embezzlement, bribery. He's achieved a 98 percent conviction rate. But he's never heard about this act and has little idea what he's getting into as he says yes.

Hanging up, he yells to his wife, Carol, in the kitchen. "That was the health department. They want me to investigate some case about human tissues."

His partner of 29 years is pleased. "I've been praying all morning about you getting more work," she says. Both are "reborn Christians." They read the Bible daily and sit up front at church on Sundays.

His curiosity piqued, Johan is faxed a copy of South Africa's Human Tissue Act and scans it.

Sect. 1: "[T]issue means ... any flesh, bone, organ, gland, or body fluid...." Sect. 28: "No person ... may receive any payment in ... the ... acquisition ... of any tissue...." Section 33: Violators "shall be ... liable ... to a fine not exceeding 2,000 Rand or to imprisonment for a period not exceeding one year...."

One year in jail or a fine of about $300. This thing has "no teeth," Johan thinks. Maybe that's why they're buying and selling organs in South Africa.

It's June 2003, and Johan is embarking on what will become one of the toughest cases of his career - not only a test of his detective skills, but also of the ethical and religious values he holds dear.

Hernani goes to South Africa

Hernani has big dreams for the $6,000 he's expecting to get for one of his kidneys. But he also has doubts. One day as he's walking home - wondering if the South Africans will take a lung or cornea, too, or just abandon him in a country where he can't speak the language - he bumps into a friend who's driving a shiny white Volkswagen. He's heard through the grapevine that this friend is one of dozens from Recife who went to South Africa and came back alive. The early ones got $10,000 for their kidneys, a fortune in a neighborhood where many earn the minimum wage - about $1,000 a year.

Hernani gets in the car. He is not normally the inquisitive type, but today he pelts his friend with questions.

"How much did you get paid?" he asks.

"Do they pay in advance?"

"How were you treated?"

"What is the operation like?"

"Do they take care of you?"

"Will I be OK?"

The friend says all the right things. Ten minutes later, Hernani gets out of the car, his mind at rest. He is going to South Africa to sell his kidney.

* * *

In the months since they met in Egipcio's, Hernani and the little bald man - he calls him Captain Ivan - have become fast friends. Ivan Bonifacio da Silva, a retired police officer, has taken Hernani under his wing, patiently explaining how the kidney switch works, and assuaging his lingering concerns.

He's also been shepherding him into a whole new world. He tells Hernani where to get the tests to prove he's healthy enough for the operation. He's with Hernani when he gets the passport that will allow him to leave Brazil for the first time in his life. And in October 2002, on the eve of Hernani's trip to Durban, Captain Ivan hands him $500 - and assures him there is another $5,500 waiting for him when he gets home.

Six thousand dollars. It's somewhere near the average going rate for kidneys in today's global organ trade. Palestinian men who sold their kidneys in Saddam Hussein's Iraq after the first Gulf War got just $500 to $1,000. They helped make Iraq the organ-trading hub of the Arab world until the latest war broke out. In the slums of Manila, where corneas, livers, and lungs are also offered for sale, kidneys fetch about $2,000, according to Nancy Scheper-Hughes, cofounder of Organs Watch, a group at the University of California, Berkeley, that tracks the trade. Some Israeli organ donors have gotten $20,000, she says. And a few American sellers have gotten $30,000 to $50,000 for their kidneys.

But $500 is more than Hernani has ever held in his hands. Captain Ivan tells him to make sure Daisy, Hernani's wife, has enough for when he's gone, and to buy some new clothes.

Hernani hardly has to be told twice. Within an hour, he's walking through the sliding doors of the Shopping Recife mall and into a new life. The lights are bright and the giant windows are filled with personal beer kegs, colorful shirts, and tiny cameras that seem to seduce him, whispering: You've got money now, you can afford it, come in, buy me.

Hernani quickly succumbs to the mall's sirens. He buys five or six polo shirts. He buys a new pair of lace-up shoes. He buys two pairs of jeans, tripling the number of long pants in his wardrobe. He goes to the food court and fulfills a lifelong dream of buying a cappuccino. At the supermarket he fills his cart with rice, beans, bread, milk, eggs, and the ultimate luxury food - meat. For about $2 he buys enough beef to feed his family for a month.

This is just the beginning, he thinks, as he sits down later that night at a fancy restaurant. Things are different now. I am somebody. I'm a consumer.

* * *

But when he opens the metal door to his house just after midnight, he realizes money can't change everything. Daisy is lying on the carpet they call their bed. She's angry. She knows he's been to see his mistress, Antonia. And she knows he has spent most of the money on himself, even though it was supposed to be the down payment on their new life. Yet no matter how much she has come to detest him over the past few years, she can't stop herself from worrying.

"Don't go," she tells him as he lies down beside her. "You don't know what might happen. They could do anything, take anything. You don't know who they are or what they want."

"Shut up," Hernani barks. "Let me go to sleep."

"It could be a trap, Hernani," she persists. "You might not get out alive."

Actually, in this brave new world of kidney selling, donors rarely die. But Daisy's fears aren't totally unfounded. In India, about 2,000 people sell a kidney each year. One study there in 2002 found 86 percent of organ sellers saying they had significant declines in their health in the three years after surgery. In the eastern European nation of Moldova, some 300 peasants sold their kidneys between 1999 and 2002. A study by Organs Watch found 79 percent of Moldovan donors with health problems in the months and years after the procedure.

But in the darkness of their house that night, with the promise of a payday to beat all paydays, Hernani ignores his wife's anxious pleading. "Daisy, I'm doing this," he says, cursing her. More harsh words are exchanged, and she flees to the next room to sleep with her son.

The next morning he pecks her on the cheek, slips quietly out the door, and heads to the airport.

* * *

Hernani lands in the lush, hilly city of Durban, which sits on the Indian Ocean. How different and luxurious things are here, he thinks. The house where his hosts keep him and several other Brazilian kidney donors is enormous. The living room alone is bigger than his whole house back home. There's even a hot tub. An interpreter stays with them all day, and a facilitator buys them a CD player so they can dance around the living room to Brazilian songs that remind them of home. Sometimes the hosts take them out to dinner. Hernani, who rarely has enough money to buy even pork, tries ostrich meat.

October 2002 blends into November. Mostly, they spend their days lying about the house, waiting for the call. When it finally comes, Hernani is whisked off to St. Augustine's Hospital, a sprawling modern complex set high on a green hillside overlooking the ocean. He and the others are, after all, here for business.

They are several of the roughly 300 Brazilian and Israeli sellers that police say were brought to South Africa between 2001 and 2003. The syndicate was run, police say, by an Israeli named Ilan Perry. He and the other organizers were making hundreds of thousands of dollars in profits. They probably picked South Africa because it has top-notch medical facilities and one of the world's best transplant-success rates. It also has weak laws regulating the sale of human organs.

Hernani has signed lots of forms, including one that says he's "related" to the man to whom he's about to give his kidney. Finally he meets this man - an Israeli named Amiram Aharoni - for the first time. Walking into the room, it's then that Hernani understands the magnitude of what he's about to do. Mr. Aharoni is all swollen and pale. He cries when he sees Hernani. He's too weak to lift himself up. But his wife passes along their message with a tender hug. "You are part of our family now," she says. "From this moment on, you are our flesh and blood."

The operation takes place on Nov. 26, 2002, and lasts several hours. Lying in two nearby operating rooms, Hernani and Aharoni undergo surgery at the same time. Hernani has three surgeons operating on him because of the complexity of the procedure, which sometimes involves removing a rib.

When Aharoni wakes up, he has a fresh kidney and a new lease on life. When Hernani comes to, he feels a tightness where the wound has been stitched shut. But three days later, when he finally boards the plane back to Brazil, he is a happy man. He is going to be rich.

* * *

That joy fades fast as he arrives back at his mother's house in Recife. It's been almost 24 hours since his plane landed, and Daisy is scowling at him. She suspects he's been to see Antonia. She's both relieved and depressed to see him alive and back in her life. She's tired of their sad marriage. She's sure he doesn't really care about the three children jumping around the street - or about Daisy herself, who dropped out of school at 14 to set up a home with him. Even after weeks on the other side of the world, the man taking a red bicycle out of the taxi doesn't even look at her.

"Luiza,go and get yourself ready. We're going into town to get you a bicycle," he shouts to his 9-year-old daughter as he hands the new bike to his son, Hernandes. Then he turns his back and walks toward the local plaza.

He's determined to have some fun. After all, he has money in his pocket - $5,500 in crisp new $100 bills handed to him by Captain Ivan under the table at a fast-food restaurant near a local branch of Citibank.

For someone who has been poor all his life, money is to be spent, not saved or budgeted. And spend it he does. In the first few months of 2003, Hernani pays $1,700 to replace the roof, the floor, the walls, the windows, and the wiring in his mother's house. He uses $1,600 to pay off her credit cards. Another $1,200 buys him a brand new Honda CG 125 motorcycle, which he insists the dealer deliver to his house so his neighbors can see. On New Year's Eve, he buys Daisy a new blouse and skirt. He figures that leaves him somewhere between $1,000 and $2,000 to spend on drink and other women. Life is good.

Paying a healthy stranger

While Hernani is busy blowing through his money, in Israel Arie Pach is hoping to avoid a life tied to a dialysis machine. But he's running out of options. He's been ruminating over them since 1995 when doctors first detected a problem with his kidneys. He knows that patients who get kidneys tend to live longer than those on dialysis. So he considers turning to his wife or sons for a kidney. Since they come in pairs, a healthy person can live on just one. But his wife and oldest son have the wrong blood type. His youngest son is a match, but he has health problems similar to Arie's. So getting a kidney from a related donor is out.

Another possibility: Signing up for Israel's national waiting list, which already has more than 500 people on it. But the wait time can be as long as four years for someone of Arie's age - those under 18 get priority - which means most go onto dialysis. For religious reasons, Israel's cadaver donation rate is relatively low, although its rate of donation among living relatives is above average. And anyway, organs from live donors are more effective than cadaveric ones.

So Arie and Mary, his wife of 36 years, feel they have no other alternative. They're left to consider paying a healthy stranger for a kidney. Mary has been an operating-room nurse for more than 25 years. She encourages Arie to find a living donor. "If you go for a transplant at the very end, after years of dialysis, your body is all worn out," she says. "If you do it before you get to dialysis, you have a much better chance of the surgery being successful."

Buying a kidney in Israel is against Health Ministry regulations, but there's no penalty associated with the rule - yet. As in many countries, the legal ground is soft. Going abroad for a kidney operation is perfectly legitimate, and in such cases questions are rarely asked about how the organ was obtained. Even under a new proposal that would punish brokers, recipients would not be prosecuted because they're victims of failing health and opportunistic organ brokers, says Meir Broder, legal adviser to the Health Ministry.

For Arie, who has spent a lifetime practicing law, the ethics of a kidney purchase are still complicated. He doesn't want, for instance, to exploit a poor person who's just trying to feed a family. Yet he's torn.

"Everyone is the boss of his own body, and if someone healthy wants to give away one of his own kidneys, I can't see why it shouldn't be done," he says. "There has to be informed consent."

Then there's the religious element. Arie and Mary aren't particularly devout, but they discuss the guidance Judaism offers. Arie finally concludes, "There really is nothing holy except for God and human life," and since "donating an organ is saving a life," it's entirely ethical.

Religious beliefs often figure in decisions about organ trading. They're invoked both to encourage and discourage it. The Old Testament story of Hagar bearing a child for Abraham (because his wife, Sarah, is "barren"), is often cited as the first case of surrogate motherhood. Some people use this scripture to justify paying someone to be a surrogate for an organ, says Dr. Scheper-Hughes of Organs Watch. Or as one Israeli doctor said to her, "God performed the first transplant" when he took a rib out of Adam and created Eve. In many Christian circles, too, there's the belief that "your body is a gift from God," says Scheper-Hughes, "or that you have use-rights over your body, but that it belongs to God."

Yet one reason Israelis rarely donate organs after death is that many Jews believe the body is sacred, and should be whole at the time of burial. Orthodox Jews believe that the deceased should be intact for the Resurrection they believe will follow the coming of the Messiah. But views are shifting.

"If someone needs to save his life and the only way to motivate someone to help him do that is by financial incentive, then I don't think they should prevent people from doing that in order to save lives," says Robert Berman, the founder of the New York-based Halachic Organ Donor Society, which has enlisted prominent rabbis to encourage donation.

"The fact is that people are dying and that there are not enough organs going around to save their lives," he says. "There's a widespread misperception that organ donation is categorically prohibited by Jewish law. It is not. Jewish law supports saving lives."

Meanwhile, after many conversations, Arie and Mary agree they're making the right choice. "This decision," says Mary, "completely changes the course of your life."

* * *

Arie soon discovers buying a kidney is a pretty easy path to take in Israel. In dialysis units, in doctors' offices, even in newspaper classified ads, the names of organ brokers - people who arrange kidney trades - are an open secret. For $60,000 to $150,000, a new kidney can be purchased.

Arie starts surfing the Web, looking at clinics in the United States that do transplant surgery. A friend suggests a medical-advice hotline run by an aide to an influential rabbi. "People call him and say, 'I need an operation' and 'Who's good?' " says Arie. He tries it and gets the name of a doctor in Tel Aviv. Soon, he's put in touch with a broker who tells him a transplant, done in South Africa, will cost $100,000, with 10 percent paid up front.

It's a lot of money, but Arie figures he can at least manage the down payment from his retirement fund.

Many Israelis, even those without great wealth or savings, find ways to cover the cost. Israel's health-insurance funds reimburse patients as much as $70,000 for any medical procedure done abroad. Technically they're not supposed to pay for illegal operations, but if it's done outside Israel, it's off their radar screen. Critics say the health-care companies are turning a blind eye to an international racket. Government and health officials say there's no way to control what a patient does outside Israeli territory.

There is an attractive economic component to this setup. Paying $70,000 for one kidney transplant is far cheaper than $50,000 a year for life in dialysis bills. But it's more than money. The transplant recipient is healthier, and has a better quality of life than a dialysis patient.

Some argue that since the trade is already flourishing, and is difficult to stop, the best way to protect sellers is to decriminalize it and create a regulated market. Michael Friedlaender is one of Arie's doctors after the operation and heads the kidney-transplant follow-up unit at Hadassah University Hospital in Jerusalem. He once opposed organ sales. Now he advocates a legal market.

Under the current system, he says, if something goes wrong during surgery, or if the financial transaction turns out to be a scam, neither the donor nor the recipient has any legal recourse. A regulated system, he says, would change that, and allow for things like malpractice suits, which help safeguard the process.

In a free market, Dr. Friedlaender argues, it's unethical not to pay for an organ.

"Someone's saving your life," he says, "and you're not going to reward him? We pay for every other service in the world." Donating an organ is one of the most valuable services, "because it saves a life."

* * *

Only a few weeks after making contact with the broker, Arie gets the call. "We have a donor for you in South Africa," the broker says. Then things move fast. Plane tickets are delivered. He gives the broker a $10,000 downpayment, with the rest payable when he's admitted to the hospital for surgery. Suddenly he and Mary are on their way to South Africa.

On April 8, 2003, they arrive at St. Augustine's. With its warm yellow walls, highly polished floors, and views of the ocean, the transplant ward is one of the most luxurious in the country. They're struck by the professionalism of the staff.

But they hit a snag.

It turns out that Arie's donor has high blood pressure and is rejected by the syndicate. This comforts Arie and Mary, and persuades them that the doctors and brokers aren't just trying to scam them or the Brazilians. But the first donor isn't the only Brazilian there. Arie and Mary often hear Brazilian music wafting through the hospital hall, and the TVs are tuned to soccer. After several days of more tests, a suitable donor is found.

Arie soon meets the young man (Arie won't reveal his name) who's going to change his life. He's tall, thin, and youthful. He grins constantly. Through a translator he says he doesn't smoke or drink. He just wants to improve his life by getting married and going to college to become an architect.

As they talk, Arie keeps trying to remember how to say "thank you" in Portuguese.

"Ob..., Ob...," he stutters.

"Obrigado," Mary chimes in.

Through his interpreter, he asks the Brazilianif he really consents wholehearteldy to giving his kidney. The young man smiles, and says, "Yes." He offers his hand to Arie, and the two men shake as they are wheeled into the operating room.

Surgery falls on the eve of Passover, the Jewish holiday that celebrates the Children of Israel's passage from slavery into the freedom of the Promised Land. As he's lying on the gurney, being wheeled into the operating room, he whispers, "Shma Yisrael," a Jewish prayer that affirms God's oneness and the commandment to love God with all one's heart, soul, and mind.

That evening, back at the hotel, Mary feels lonely and apprehensive. Some local Jewish families have invited her to celebrate Passover with them, but she doesn't feel like being cheery and social. In her room, she lights some candles and reads the Passover story. Perhaps the surgery will finally let her husband find a new freedom of his own.

The next day she sees him, and he doesn't look well. He's pale gray and connected to machines she's seen all her professional life, but it's different when it's her husband. To her relief, the doctors say the surgery was a success.

In the following days, Arie meets his donor again. They pose for photographs. The Brazilian wraps an arm around Arie, flashes a thumbs up sign, and beams. In his bright red shirt, he looks like a fan whose team has just won the championship.

The ring is busted

Unknown to him, under South Africa's 1983 Human Tissue Act, Arie and his donor have broken the law. But the organ brokers and doctors are the ones making the biggest profits - and are the real targets of the police. Buying and selling kidneys across three continents is, in some ways, the perfect 21st-century crime. That's what South African investigator Johan Wessels realizes as he gets further and further into his new case. For one thing, it occurs in several jurisdictions, all of which are thousands of miles apart. And it's hard to determine where exactly the crime - handing over the money - takes place. And if one country starts cracking down, the syndicate can hop to another.

In working the case, Johan has teamed up with a group from the elite Commercial Branch, South Africa's equivalent of the FBI's white-collar-crime unit. The team is headed by Capt. Louis Helberg, a reserved man.

By the middle of 2003, the team has a firm idea of what's going on. Donors are getting $6,000 to $18,000 for their kidneys. They're coming from Israel, Brazil, and maybe Russia and Romania, given the Eastern European-sounding names on the hospital records. Two doctors at St. Augustine's appear to be heavily involved. It looks as if some of the South Africans have pocketed as much as $450,000 doing more than 107 operations.

Police say the organizers meet 11 of the 12 criteria for a "syndicate" - a criminal enterprise akin to the mafia. There's only one criterion the group hasn't met: no one has been killed, say the investigators.

* * *

After one long day working on the investigation, Johan, Captain Helberg, and another detective head to a burger joint. They get some weak coffee and fall into conversation about the case.

"How far would you go if one of your kids needed a kidney?" asks one detective. The question opens a debate on the validity and ethics of the very law they've sworn to uphold.

For most people, the initial response to buying or selling a body part is revulsion. It's what bioethicists call "the yuck factor." But the moral underpinning of that feeling - which in turn becomes codified as law - is often hard to articulate, says Walter Robinson, a pediatrician and bioethicist at Harvard Medical School in Cambridge, Mass. "It's a violation of 'naturalness,' " he says. "But 'naturalness' is difficult to describe." It can emanate from people's moral or religious values, subtle prejudices, or tradition.

Personal or societal definitions of "naturalness" can change, Dr. Robinson observes. They have shifted in the US for instance, regarding interracial marriage and homosexuality.

Revulsion aside, "If one of mine was sick, I'd do anything," even though it's illegal, Johan says, thinking of his two children. "I'd borrow lots of money. I'd even sell the farm," he says, referring to one of his favorite places in the world, a 700-acre spread that's been in his family for four generations.

It's a typical parental response - doing anything for a child. In fact, growing numbers of doctors and ethicists agree that people like Johan or Arie should be able to buy kidneys, and that people like Hernani should be able to sell them. They argue, for instance, that banning organ sales robs sellers, who are often poor, of a rare option to escape poverty. They also argue that high-minded efforts to shield the poor from themselves can be paternalistic or hypocritical. "If the rich are free to engage in dangerous sports for pleasure ... it is difficult to see why the poor, who take the lesser risk of kidney selling ... should be thought so misguided as to need saving from themselves," says Dr. Friedlaender in Israel.

But as the detectives' coffee cools, they weigh the other side, too. They wonder if rumors about "organjacking" - people being killed for their organs - might be true. Critics say the current system has already jump-started a dangerous commodification of the human body, which could turn the world's slums into reservoirs of body parts for the rich. Today, in Manila's slums, the selling of kidneys has led to sales of lungs and corneas.

As the detectives talk it through, Johan's views develop. "Life is already really cheap in our society," he says later. "People will kill each other for a firearm and a little cash." And if you start giving people money for their kidneys, "you're going to start finding a lot of dead bodies with no organs."

These kinds of gruesome scenarios are what seal Johan's opinion. The detectives get up from the table, strengthened in their resolve to break open the case.

* * *

A few weeks later, Johan adds another plank to his position. As he's eating breakfast, he tunes into an American TV news show. A reporter is interviewing a mother whose 17-year-old son, as Johan recalls, was killed in a car crash. With the mother's consent, doctors salvaged 47 organs and tissues from the boy's body - corneas, kidneys, liver, lungs, heart. "I didn't know they could get that many organs from one body," Johan thinks to himself.

The reporter asks if the mother thinks she should be paid for all the organs her son gave away freely. How could I take money for them? Johan remembers her saying. God gave each of us the body we use when we're alive. He gave it to us for free. How could we charge someone else for part of it? He calls his wife right away.

"This makes more sense to me as a Christian than anything else I've heard," he says to her.

* * *

The detectives have been toiling for months now, slowly piecing the trafficking puzzle together. But in late November they get a major break. The police team gets a call, out of the blue, from an officer at a nearby police station. The cop has two Israelis with him. One is accusing the other of stealing $18,000, and there's something about a kidney. When the detectives later question the two men, they can't believe their ears.

One man, known as S. Zohr, admits he received $18,000 for agreeing to sell his kidney. He'd actually been lying on the operating table at St. Augustine's, just moments away from surrendering his organ to an ailing Israeli man named Agania Robel, when he got spooked. Zohr jumped off the table, grabbed his clothes, and bee-lined for the airport, trying to take the $18,000 with him.

But then, a man named Shushan Meir, who later is charged with being part of the syndicate, called the police and told them Mr. Zohr was stealing the money. Mr. Meir apparently hoped, strangely enough, that the cops would help prevent this illegal deal from going sour. It was the final confirmation the police needed to bust up the ring.

On the morning of Nov. 27, 2003 - a year and a day after Hernani went under the knife - Johan, Helberg, and a police team that includes a photographer and several plainclothes detectives converge on the back parking lot at St. Augustine's. They walk quickly up the hill into the facility's transplant division.

Helberg, the team leader, announces that they have a search warrant and will be seizing files. Johan adds that he's an independent investigator looking into crimes committed under the Human Tissue Act. He doesn't need a search warrant and can look at any of the clinic's files at any time. He steps into a side office where a whiteboard hangs on the wall. Scrawled on it are two names - "A. Robel" and "Rogerio Bezzera" - and today's date.

"What are those?" he asks Lindy Dickson, a staff member who would later be arrested and charged with complicity in the scheme. She tells him the two men are, at this moment, on operating tables upstairs.

Robel. That's the guy who was left stranded when Zohr jumped off the table last week, Johan realizes. And he's already been paired up with another donor, a Brazilian named Rogerio Bezzera da Silva. With this, Johan gets a glimpse of the efficiency and sophistication of the syndicate. Only days after one donor gets cold feet, the group has another one on the operating table. This one, he will learn, is getting only $6,000 for his kidney. Robel, the recipient, is paying $45,000 for a new organ.

Police decide against arresting the two men while they're on operating tables, but several days later, they make three arrests. Robel, the recipient, pleads guilty. He's fined about $770 and returns to Israel. Two apparently low-level syndicate operatives, including Meir, are charged. One makes a plea bargain, while Meir will be tried beginning July 13. Mr. Bezzera da Silva isn't charged, but he forfeits his $6,000.

That same week, Brazilian police also arrest two Israelis and nine Brazilians.

The $6,000 is gone

Nearly a year after his South African trip, every last bit of Hernani's $6,000 is gone. Daisy sells popsicles to pay the bills. Hernani sold his motorbike after sliding off the road one rainy night and running into the back of a truck. He now walks with a limp.

Hernani continues to see Antonia. There is no dialogue between Hernani and Daisy, only the occasional monotone orders for her to get the phone, go shopping, mind the children. He will not hold 9-year-old Luiza's hand when they walk around the neighborhood together, and he cannot, or will not, pay for her to play organized soccer, even though she controls the ball better than half the boys during their games in the street.

Hernani's plight is common among kidney sellers. According to the study in India, organ selling actually increased poverty. Some 54 percent of sellers were extremely poor before losing a kidney. A year later, 74 percent were still in debt, and the average family income had declined by about 30 percent.

For Hernani, things could hardly get worse.

But they do.

On Tuesday, Dec. 2, 2003, Hernani, like 40 million other Brazilians, is watching the nightly news on TV Globo. He's had a tough day. He's heard that the friend with the white VW, who was instrumental in convincing Hernani to sell his kidney, was arrested in a surprise raid that morning. No one knows why the Brazilian FBI would be after him.

Sitting on the couch that night with another friend, Hernani discovers why. Police in South Africa have broken up an international organ-trafficking ring, he hears the announcer say. Authorities have detained 11 people in the last 24 hours and expect to make more arrests. The words "organ trafficking" and "arrests" jump out at him, just like that day when he heard a man behind him say: "We pay people $6,000."

But this time he's full of dread.

"Man, you've got to get out of here," his friend warns.

One word that keeps coming into his head: "Why?" I have done nothing wrong, harmed no one. I crossed the world to give life to a dying man. I sold only what was mine. Why are they doing this? Why me? I am going to jail, Hernani thinks to himself. Within minutes, he has changed his clothes and slips out into the night. Soon he's banging on the metal door of a local hot-sheet hotel, where rooms are rented by the hour. The receptionist is surprised to see a single man looking for a room, but he accepts Hernani's credit card and hands him a key.

Afraid and agitated, Hernani lies on the grotty hotel bed staring at himself in the mirror overhead. He's not reviewing his decision to sell his kidney. He's not worrying about the police finding him. He's worrying about whether he has enough money in the bank to pay the hotel bill - about $7 per night.

* * *

As the investigation continues into 2004, Johan is still unsettled about his religious perspective on organ sales. As he drives home one night, he realizes he's had a change of heart from his first inclination to "do anything" to save himself or one of his family members, including buying a kidney. Knowing what he knows now, he'd try to figure out something legal. For instance, he, his brother, and his best friend all have O-negative blood. And they've got an understanding: If one of them ever needs blood - or maybe an organ - the others would step up. He knows people who have done so. A couple of years ago, a woman at his church donated her kidney to a fellow church member. "It was such a huge sacrifice," he thinks.

He realizes he's become pretty passionate about this stuff. But he still hasn't found biblical guidance.

That night at home he goes to his bedroom and picks up his Bible. He sits down on the bed and speaks into the silence. "Lord, there has to be something in this book of yours about this," he says.

He opens to a verse he hadn't considered before. Romans 12:1. He reads these words from Paul's letter: "Give your bodies a living sacrifice."

Paul may have meant something else when he wrote it, but to Johan it now feels important to donate his organs after death. "Jesus sacrificed himself for everyone - gave his whole body for all mankind." The least we can do, he thinks, is give part of our body to someone else in need. Finally he has what he's been looking for.

* * *

Today, 14 months after his surgery, Arie Pach, now 57 years old, is living a new life of freedom - sort of. His youngest son is getting married this summer, and Arie will be there under the wedding canopy.

But he's told he'll have to take immunosuppressant drugs for the rest of his life. And he's photosensitive; he can't go out in the midday sun much and finds himself missing a day at the beach. He used to like to swim, but now, on doctors' orders, he has to beware of contracting an illness by going to public pools.

"I'm more philosophical and more resigned about my own fate," he says on a cool afternoon at home, where pastel flowers are in bloom in the tiny backyard garden. "There are so many things in life that could have been worse, but thank God I'm fine now," he says. And even though he has a new kidney from across the world, he's still searching for a better solution. "I haven't become religious," he says, "but I guess you could say I pray more, to ask for a refuah shlema - a full healing."

Epilogue

As far as investigators know, the syndicate that orchestrated kidney swaps for at least two yearsin Durban between Brazilians and Israelis is dismantled. But the global trade - and the debate about it - rolls on.

In South Africa, four alleged syndicate members have been charged and await trial. Johan Wessels and Captain Helberg and his team have expanded the investigation to hospitals in Johannesburg and Cape Town.

In Brazil, Captain Ivan is one of 28 ringleaders who have been indicted. In all, some 50 cases are being investigated by a parliamentary committee, which is expected to submit its findings in September. Hernani has been helping, despite receiving death threats. When he testified before Parliament in January, he wore sunglasses and a shirt up over most of his face to hide his identity.

Daisy, meanwhile, has made up her mind to leave him - as soon as she can raise the money to support herself and their children. At one point, she considered selling a cornea. She's heard the going rate is nearly $30,000.

Around the world, meanwhile, organ-sale laws are shifting. In Israel, for instance, one proposed law by the Ministry of Health aims to halt the country's involvement in the trade by targeting organ brokers - including penalties of up to three years in prison. Another proposal would allow voluntary organ donors to have all of their related healthcare costs picked up, as well as compensation for lost time at work when recuperating from the surgery. Others in Israel, such as Friedlaender, argue that the government should set up a fund to give substantial compensation to those who volunteer to be living donors.

In the US, Wisconsin recently became the first state to give living donors a tax deduction of up to $10,000, to write off lost salary, and medical and travel costs. At least 14 other states are considering similar measures. And in April, President Bush signed the Organ Donation and Recovery Improvement Act, which reimburses living donors for expenses incurred during the process and funds research projects aimed at increasing donations.

But laws may not keep pace with a global market moving at the speed of commerce. There is, for instance, skyrocketing demand for pieces of livers, which can grow into a fully functioning organ in a recipient. Now a website - liver4you.org - promises "transplant surgery in as short as 10 days" in the Philippines.

Sitting in his office in Jerusalem, Friedlaender points to a small trinket hanging from one of his bookshelves. One of his patients brought it to him a couple of months ago after going abroad to get a new kidney. It's from a country that may already have replaced South Africa as a hot spot for body-part trading.

It's a red paper lantern from China.

Editor's note

This report was written as a nonfiction narrative. Specific scenes and dialogue are based largely on recollections of those who participated in the kidney-transplant trade, but did not know then it was illegal in South Africa. The reporting was done over five months in four countries.

Correspondent Andrew Downie flew to Recife, Brazil, and met with Hernani Gomes da Silva and his wife, Daisy, four times over four days, reconstructing what happened. Later, he confirmed more facts and details by phone with the da Silvas, their attorney, and Brazilian police.

The Monitor paid Mr. Gomes da Silva its standard photo fee for use of a picture of him with his Israeli kidney recipient in South Africa. Normally, the Monitor does not pay interview subjects for information to avoid conflicts of interest. In this instance, that risk seemed marginal.

Staff writer Abraham McLaughlin went twice to Durban, South Africa. He spent four days meeting with police and investigators and visiting St. Augustine's Hospital. From South African court documents, and a photo provided by Hernani, the Monitor tracked down the Israeli recipient of Hernani's kidney. But the recipient declined to be interviewed by staff writer Nicole Gaouette. In Jerusalem, staff writer Ilene R. Prusher met twice with Arie Pach and his wife, Mary, who were willing to relate their experience. They also spoke nearly a dozen times on the phone.